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Patrick Platt

HISTORY AND PHYSICAL EXAMINATION Patient Name: Patrick Platt Patient ID: 771033 Room No: 560 Date of Admission: 08/30/—- Admitting Physician: William Payne, MD Admitting Diagnosis: Rule out fracture of left arm. CHIEF COMPLAINT: Pain and swelling, left upper arm. HISTORY OF PRESENT ILLNESS: The patient is an elderly male, who fell four days prior to admission.

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He noted immediate pain and swelling in the area just above his left elbow. He presented to the emergency room for treatment. PAST HISTORY: Past illnesses include whooping cough as a child.

Tonsillectomy in the past. No known allergies to medications. FAMILY HISTORY: No hereditary disorders noted. Mother and father are deceased. Two brothers are alive and well. One sister has adult-onset diabetes mellitus. SOCIAL HISTORY: The patient is married and has two children. His wife does not work outside the home. (No mention of tobacco or alcohol use). PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, well-nourished male who appears to be in moderate distress with pain and swelling in the upper left arm.

Vital signs: Blood pressure 140/90, temperature 98. 3 degrees Fahrenheit, pulse 97, respiration 18. HEENT: Head normal, no lesions, Eyes, arcus senilis, both eyes. Ears, impacted cerumen, left ear. Nose, clear. Mouth, dentures fit well, no lesions. NECK: Normal range of motion in all directions. (Continued) HISTORY AND PHYSICAL EXAMINATION Patient Name: Patrick Platt Patient ID: 771033 Date of Admission: 08/30/—- Page 2 INTEGUMENTARY: Psoriatic lesion, right thigh, approximately 1 mm in diameter.

CHEST: Clear breath sounds bilaterally. No rales or rhonchi noted. HEART: Normal sinus rhythm. There is a holosystolic murmur. No friction rubs noted. ABDOMEN: Normal bowel sounds. Liver, kidneys, and spleen are normal to palpation. GENITALIA: Tests normally descended bilaterally. RECTAL: Prostate 2+ and benign. EXTREMITIES: Pain and swelling noted above the left elbow, other upper extremities normal. No cyanosis or clubbing. The legs demonstrate 2+ pitting edema to the knees.

NEUROLOGIC: Crainial nerves II through XII intact, memory intact, sensation intact to light touch. ASSESSMENT AND PLAN: The patient was sent for plain film of the left arm, which revealed a fracture of the left humerus. The fracture was reduced in the emergency room. X-ray revealed anatomic alignment. He was released to home with a prescription for a nonsteroidal anti-inflammatory and instructions to elevate his arm. He will follow up in the office in three days. PROGNOSIS: Good. _________________________ William Payne, MD WM:R D:08/30/—- T:09/01/—-